Multidisciplinary approach to prevent spinal cord ischemia after thoracic endovascular aneurysm repair for distal descending aorta

Abstract

Background: This article discusses the multidisciplinary approach to prevent spinal cord ischemia (SCI) with reference to the incidence of SCI after thoracic endovascular aneurysm repair (TEVAR) associated with closure of the intercostal-lumbar artery that supplies the Adamkiewicz artery (ICA-AKA).

Methods: We reviewed 60 patients [49 men, 57 to 89 years old] who underwent TEVAR (TAG [W. L. Gore & Associates, Flagstaff, AZ] 42; the Matsui-Kitamura (Kanazawa, Japan) 10; Talent [Medtronic Inc, Santa Rosa, CA] 5; TAG and Talent 3) for part of or the entire distal descending aorta between T7 and L2. These patients had frequently undergone aortic surgeries: ascending aorta (4), aortic arch (25), descending aorta (4), thoracoabdominal aorta (3), and abdominal aorta (19). The multidisciplinary approach consists of identification of the ICA-AKA by magnetic resonance angiography or computed tomographic angiography to avoid unnecessary coverage of the ICA-AKA, in combination with monitoring of motor evoked potentials, augmentation of mean arterial pressure (> 80 mm Hg), and cerebrospinal fluid drainage.

Results: Spinal cord ischemia occurred in 4 patients and patent ICA-AKAs were covered in 3 of them. The overall incidence of SCI was 6.7% and 9.4% in the group of 32 patients whose patent ICA-AKAs were covered by TEVAR. After treatment for SCI, 3 patients regained full ambulatory ability. Significant risk factors were identified as the artificial graft at the proximal landing zone, the number of covered zones (>8), the length of aortic coverage (>250 or >300 mm), and the length of the uncovered distal aorta (<60 mm).

Conclusions: A multidisciplinary approach is essential to prevent SCI after TEVAR for the distal descending aorta. This approach includes the preservation of patent ICA-AKAs after their identification, early diagnosis of SCI during TEVAR by monitoring motor evoked potentials, and prophylaxis and treatment of SCI by increasing mean arterial pressure to at least 80 mm Hg and performing cerebrospinal fluid drainage.